President Obama is applauded after signing the Affordable Care Act into law on March 23, 2010. / Charles Dharapak, AP

by Kelly Kennedy, USA TODAY

by Kelly Kennedy, USA TODAY

WASHINGTON - The majority of tax subsidies to help Americans pay for health insurance starting in January will go to working families, according to a nationwide study to be released Thursday and obtained by USA TODAY.

About 25.7 million people who fall between 138% and 400% of the poverty level - or below $46,000 for a single adult and $94,000 for a family of four - will be eligible for funds that will go directly to an insurance plan that they choose. According to the Congressional Budget Office, those subsidies will cost about $350 billion from 2010 to 2019, but taxes and savings built into the law will offset them.

"This reaches deeply into the middle class, as well as moderate-income families," said Ron Pollack, founding executive director of Families USA, which released the national report. "This is a group that's really deserving of priority help."

The 2010 health care law, also known as the Affordable Care Act, created state health care exchanges where residents can shop for health insurance policies available in their states. The exchanges are state- or federal-run websites where residents can see a list of plans, their costs and benefits and whether they are eligible for any subsidies to help them pay for that insurance.

Those with employer-paid insurance may keep that insurance.

Most Americans, Pollack said, don't know how the exchanges will work or that they are eligible for financial help to pay for insurance. That's why Families USA released the report, he said.

The report shows that families that make between $47,000 and $94,000 will receive half the money, that 88% of the credits will go to working families, and that those up to the age of 36 are most likely to be eligible. Families USA did not include people who fall below 138% of the poverty line because, in the states that will expand Medicaid, they will not need subsidies.

The law calls for the expansion of Medicaid, the federal-state program that provides health care to low-income citizens. So far, 25 states have approved expanding Medicaid, while 14 have decided not to participate.

Some Americans who buy insurance under the exchanges will face sticker shock, said Robert Zirkelbach, spokesman for America's Health Insurance Plans. That's because, he said, insurers may no longer charge young, healthy people less for premiums while requiring older and sicker people, or those with pre-existing medical conditions, more money for their insurance.

"There's broad agreement that for the new reforms to work, there needs to be high participation in the health care system," Zirkelbach said. "But the young and healthy may still decide not to buy insurance and may only buy it when they become sick."

The Congressional Budget Office found that 40% of people in individual-market plans will not be eligible for subsidies, Zirkelbach said. And, those who fall between 250% and 300% of the federal poverty level would receive only enough to pay 42% of the second-lowest-ranking plan offered by the health care exchanges.

And, he said, some people in low-premium, high-deductible plans will be required to buy plans that offer better benefits, which may also cause costs to go up.

"Affordability is the key for all of it to work," he said. To that end, he said insurers are coming up with ways to save money, such as by changing how providers are paid, offering preventive care or rewarding healthy behaviors.

The Affordable Care Act states that an older person may not pay more than three times what a younger person pays, and that insurers may not reject someone based on health status. AHIP would like the age rating raised to five to one.

Those who will pay more represent just a "tiny sliver" of the population, said Linda Blumberg, who recently co-wrote a study about the subsidies for the Urban Institute, a non-partisan think tank that looks at economic issues.

In some cases, they will pay more for better benefits, but in the past, insurers have been allowed to exclude benefits, such as prescriptions or diabetes care, for those with pre-existing conditions. And, young women have always paid more than young men, said Blumberg, a senior fellow in the health policy department of the institute.

Those who fall in the high end of the federal poverty level would pay more, "But we're talking about a difference of $270 over the course of a year," Blumberg said.

Concentrating on a young, healthy man's premium increase without talking about all the premiums that will go down doesn't present a fair picture, she said.

"Young men are completely advantaged today because they're not hit with this huge premium bump for being a woman," she said. "Under the Affordable Care Act, you can't discriminate based on gender."